Armed with new rules from CMS, UnitedHealthcare is making some moves in its Medicare plans that could hit Johnson & Johnson's Remicade and jump-start biosims from Pfizer, Merck & Co. and more.
The insurance behemoth will roll out step therapy to control costs on pricey biologics, including Remicade, which has managed to hang on to market share despite the multiple biosims now on the market. Anemia drugs Procrit from J&J and Aranesp from Amgen will also face the new barriers.
Which drugs could reap the benefits? Pfizer’s Inflectra and Merck’s Renflexis—both Remicade biosims—are now preferred on Medicare Advantage plans, UnitedHealthcare said in a bulletin. Pfizer’s Retacrit, a biosimilar to Procrit and Amgen’s Epogen, is preferred in the erythropoiesis stimulating-drug category.
Step therapy—which requires patients to try the preferred drug first—won't apply to Amgen’s Epogen or Roche's Mircera, according to the document, and it won't apply to patients already taking the drugs, either.
As part of the Trump Administration's plan to control drug costs, the Centers for Medicare & Medicaid Services said in August that it would allow Medicare Advantage plans to negotiate drug prices and use step therapy to help control pharma spending. UnitedHealthcare celebrated the decision at the time, while the American Medical Association said it could cause “unnecessary red tape” and coverage rejections.
UnitedHealthcare's decision could boost the U.S. biosimilars market, which has so far been slow to take off for a variety of reasons, including drug contracting with payers. Despite the fact that it’s facing two biosimilars, Remicade has retained much of its market share. Pfizer argues in a lawsuit that J&J’s contracting strategy to protect the drug is “anticompetitive.”
UnitedHealthcare’s Medicare Advantage changes come about two months after Express Scripts released its formulary for 2019, kicking off 48 drugs. The list included 11 specialty drugs facing cheaper branded rivals or biosimilars.